Generality
Pericarditis is the inflammation of the pericardium, which is the membrane that surrounds, supports and protects the heart. The causes of this disorder are different, sometimes not recognizable even after an accurate diagnosis.
The therapy consists of several pharmacological treatments, applied according to the characteristics of pericarditis. Surgery is required only under extreme conditions.
What is the pericardium?
The pericardium is the membrane that surrounds the heart and the root of the main blood vessels that depart from it (aorta, pulmonary arteries, hollow veins and pulmonary veins). The pericardium consists of two layers, separated from each other by the pericardial fluid .
The outermost layer is the so-called fibrous pericardium .
The innermost layer, however, is the serous pericardium ; it adheres perfectly to the heart and to all its inlets and consists of two sheets of cellular tissue, called parietal leaflet and visceral leaflet.
Figure: the pericardium: position and anatomy. From the site: anunexpectederror.blogspot.it
The pericardial fluid, whose normal volume is about 20-50ml, serves to reduce the friction and the rubbing of the two layers constituting the pericardium.
DANGER FUNCTIONS
In addition to acting as a lubricant, the pericardium has several other functions.
It is essential to fix and maintain the heart in the correct position within the mediastinum . It acts as a defensive barrier against viral or bacterial infections that could compromise cardiac activity. Finally, avoid excessive dilation of the heart when it is affected by particular pathologies.
What is pericarditis?
The term pericarditis refers to the inflammation of the pericardium, that is, the thin membrane that surrounds and protects the heart .
Inflammation of the pericardium is characterized by irritation, swelling and, sometimes, effusion: in other words, the so-called inflammatory edema.
Pericarditis manifests itself with chest pain, very similar (in some aspects) to that caused by heart attack or pulmonary disorders. However, unlike these pathological situations, it is less severe.
TYPES OF PERICARDITES
There are different types of pericarditis:
- Acute pericarditis
It is defined as acute when the symptoms last less than three months. In general, with appropriate care, the acute type of disorder resolves within a few weeks.
- Recurrent pericarditis
Recurrent is defined, when the patient is affected by more consecutive acute pericarditis.
- Chronic pericarditis
It is defined as chronic when the symptoms last more than three months. It is considered a complication of acute pericarditis.
Epidemiology
Figure: comparison between a normal heart (left) and a heart with pericardial effusion (right). The arrows indicate the pressure that the accumulated fluid exerts on the heart. From the site: cardiachealth.org
Pericarditis is a common circumstance, but it is not always diagnosed. The non-recognition is due to different reasons: it can be the consequence of a more serious pathology or it can resolve spontaneously in a few days, without alarming the patient.
Pericarditis is a disorder that can occur at any age; however, the most affected individuals are adults, between 20 and 50 years old.
Men are generally more affected than women. Furthermore, people with a first episode of pericarditis are more likely to have similar events (recurrent pericarditis) in the future.
Causes
Pericarditis pain arises following a change in the composition of the pericardial fluid . The latter, in fact, filling itself with inflammatory cells, jeopardizes its lubricating function and causes friction and friction between the fibrous and serous layers; friction and friction, which manifest themselves with the painful sensation.
Furthermore, sometimes it may happen that the liquid increases in volume, thus exerting painful pressure on the heart. This situation is also known as pericardial effusion .
POSSIBLE CAUSES
The possible causes of pericarditis and their mechanisms of action are now almost entirely known. What is still problematic, in some cases, is the exact recognition of the specific cause. This uncertainty remains even after subjecting a patient to a detailed diagnosis.
It is for this reason, therefore, that very often one speaks of idiopathic pericarditis, referring, with this term, to the fact that one is not able to establish the precise reason, among the many hypothesized.
Usually, the cause of the disorder is a viral infection, but bacterial infections, autoimmune diseases, tumors, kidney failure, etc. cannot be ruled out.
WHEN THE CAUSE IS A VIRAL INFECTION
The most common viral infections are those sustained by enteroviruses . Often, these viruses manifest themselves, first, with a cold or with meningitis and, subsequently, with a pericarditis.
Next to enteroviruses, there are: adenoviruses, that is those that also cause pneumonia, bronchitis and some forms of myocarditis; the Epstein-Barr virus; cytomegaloviruses; some herpes simplex viruses; influenza viruses; the hepatitis C virus; the AIDS virus.
CAUSES LESS COMMON
Pericarditis, as anticipated, as well as from viruses, can also be caused by other causes. These are less common but equally important situations.
- Bacterial infections
It has been found that individuals with tuberculosis often develop pericarditis at the same time or later.
- Autoimmune diseases
An autoimmune disease occurs when an organism's immune system turns against the body itself, attacking its organs. An association between pericarditis and rheumatoid arthritis, lupus and scleroderma has been observed.
- Radiotherapy
People with lung cancer and radiation therapy are more prone to pericarditis.
- Kidney failure
An association has been established between the two disorders, but the reason is unclear.
- Hypothyroidism
As with kidney failure, a link was found between the two conditions, but the reason is not known.
- tumors
Several tumors, especially when they spread metastasize to the rest of the body, also cause pericarditis.
- Heart attack
A heart attack can cause inflammation of the pericardium at the time of its onset or even months later. If it happens later, we talk about Dressler syndrome.
- Pulmonary embolism
The presence of a pulmonary embolus can also occur with pericarditis.
- Complications of heart surgery
Heart surgery can cause inflammation of the pericardium layers as a complication.
- Complications of a car accident
The cause of pericarditis is, in these cases, thoracic trauma.
- Complications from taking medications
It has been observed that certain drugs, such as penicillin, phenytoin (anticonvulsant), warfarin (anticoagulant), procainamide (anti-arrhythmic) and some anti-tumors, cause inflammation of the pericardium in some individuals.
CAUSES OF RECURRING PERICARD
Recurrent pericarditis is a curious case, as the mechanism that causes it is not yet clear.
A first theory holds that at the origin there is an anomalous and delayed immune response. In some respects, this hypothesis is reminiscent of an autoimmune disease, in which antibodies attack the organism that they should instead defend. In recurrent pericarditis, it appears that this phenomenon occurs from time to time.
A second theory holds that the abilities, possessed by some viruses, allow them to "hide" in the pericardial cells and to show up at a distance of months, in a repeated way.
Finally, the third theory focuses on corticosteroid drugs. In fact, according to statistical data, it has emerged that patients with pericarditis, treated with these drugs, are more exposed to subsequent relapses.
Symptoms and Complications
To learn more: Pericarditis symptoms
The main symptom, whatever the cause that triggered pericarditis, is chest pain, felt just behind the breastbone.
The rest of the symptomatology depends on the reasons that caused the inflammation of the pericardium: the patient, according to the cases, can therefore manifest fever, fatigue, shortness of breath etc.
THE THORACIC PAIN
Pericarditis chest pain is sudden, acute and excruciating . Usually, it is felt behind the sternum, on the left side. In some cases, it can branch out to the right shoulder and neck.
Some patients describe pain as a discomfort that produces a sense of pressure in the chest.
Coughing, breathing deeply, eating or lying down are acts that exacerbate the painful sensation. Conversely, sitting or leaning forward are positions that produce relief.
Pericarditis and heart attack chest pain are very similar, so it is impossible to recognize them, except with appropriate diagnostic investigations. Therefore, although pericarditis is not a particularly serious pathological condition (except for those forms sustained by serious pathological conditions, such as a tumor, a cardiac problem etc.), chest pain such as the one just described deserves great attention, both by who is affected by it is from the doctor.
THE OTHER SYMPTOMS
Depending on the causes that caused the pericarditis, the patient may experience the following symptoms and signs:
- High fever
- Shortness of breath
- Fatigue and sense of weakness
- Nausea
- Dry cough
- Swelling in the legs or abdomen
SYMPTOMS OF THE RECURRING DANGER
Recurrent pericarditis can occur in two ways: persistent or intermittent .
It is persistent, when the symptoms appear shortly after stopping drug treatments (for example, NSAIDs).
It is intermittent, on the other hand, when the symptoms reappear months later, if not even years. Often, in these cases, we come across so-called Dressler syndrome, whose original cause is a heart attack.
COMPLICATIONS
Chronic pericarditis is considered a complication of acute pericarditis. It is defined as chronic when the symptoms and signs it determines last for more than three months.
There are two forms of chronic pericarditis:
- Exudative chronic pericarditis
Characteristics: inside the pericardium there is a small excess of liquid (pericardial effusion) due to inflammation. The quantities are modest, but they cause persistent pain, a sense of fainting and shortness of breath.
Causes: tuberculosis, hepatitis, tumor metastases and post-surgical heart complications. Sometimes, there is no clear explanation.
- Constrictive chronic pericarditis
Characteristics: a prolonged inflammation can stiffen the membrane that composes the pericardium and make it lose elasticity. In this way, the heart struggles to perform its pumping action because it can no longer fill itself with blood and contract as it should. The classic symptoms are shortness of breath, fatigue, abdominal pain, nausea and vomiting.
Causes: tuberculosis, effects of radiotherapy and complications after heart surgery. Sometimes, there is no clear explanation.
Alongside these two particularly serious forms of chronic pericarditis, which can endanger the patient (or at least require surgery), there is a third serious complication: the so-called cardiac tamponade .
Symptoms and signs of cardiac tamponade:
- Hypotension (drop in blood pressure due to reduced blood supply)
- Sense of fainting
- Blurred vision
- Palpitations
- Confusion
- Nausea
- General weakness
- Loss of consciousness
The condition of cardiac tamponade is established when the pericardial fluid increases in a very high way (severe pericardial effusion), so that the activity of the heart is seriously compromised. In some respects, it resembles chronic exudative pericarditis, but with even more dramatic effects: the patient, in fact, suffers from numerous disorders and needs appropriate surgery. The most common causes are tuberculosis bacterial infections and tumor metastases.
WHEN TO REFER TO THE DOCTOR
It is advisable to consult a doctor when chest pain occurs in the ways described above: sudden, acute, excruciating and a sense of pressure. In fact, although pericarditis is not in itself a serious pathological condition, it still deserves due attention, because it could have originated from much more dangerous circumstances (heart attack, pulmonary embolism, etc.).
Diagnosis
The first step, to establish a correct diagnosis of pericarditis, consists in a complete physical examination of the patient. After that, we proceed with more specific checks, such as blood tests and instrumental exams.
EXAMINATION OBJECTIVE
The objective examination begins with the anamnesis, that is with the collection of information related to the symptomatology and the clinical history directly from the voice of the patient (or of the relatives).
The doctor, therefore, asks several questions to the patient, to understand if in the recent past one of the aforementioned causes of pericarditis has occurred (viral infection, bacterial infection, car accident, heart surgery, etc.).
Then, proceed with the stethoscopic check. Cardiac auscultation, by means of a stethoscope, allows us to recognize a harsh noise, like something scratching. This noise is the result of rubbing between the two layers of pericardium and the abnormal pericardial fluid.
BLOOD TESTS
Checks on a blood sample are used to track the possible presence of infections (viral or bacterial) in progress. Furthermore, it can also be useful to take and analyze a sample of pericardial fluid, as it can provide a lot of information.
INSTRUMENTAL EXAMINATIONS
Figure: X-ray of a thorax of a person with pericarditis. From the site: circ.ahajournals.org
The instrumental tests are fundamental to confirm the pre-diagnosis and not only: in fact, through them, the anomalies at the level of the pericardium, the triggering causes and the possible correlated pathologies are clarified.
- Electrocardiogram ( ECG ). By applying electrodes on an individual's skin, the electrical activity of the heart is measured. If the person under test actually suffers from pericarditis, the doctor recognizes specific abnormalities in the heartbeat.
- Chest x-ray . It allows to evaluate the shape and size of the heart. The heart of a patient with pericarditis appears larger due to the accumulation of pericardial fluid.
- Echocardiogram . It provides an anatomical image of the heart and its structures, including pericardium. If there is any change in volume, this is highlighted.
- Computerized axial tomography ( TAC ). Very detailed images of the heart and pericardium are obtained. It is essential to clarify the causes and to exclude diseases other than pericarditis, but with similar symptoms. The test uses ionizing radiation, slightly harmful to the patient.
- MRI scan . Provides images of the pericardium and its possible changes. The exam is not at all harmful to the patient.
Treatment
The choice of the most appropriate treatments depends on the causes and the severity of pericarditis. Therefore, a precise diagnosis is essential, which clarifies the characteristics of the disorder.
Usually, the administration of analgesic and anti-inflammatory drugs is required; it is rare to resort to surgery, however indicated in cases where pericarditis is due to very serious causes (heart attack, cardiac trauma, tumors, tuberculosis, etc.).
NEED FOR HOSPITALIZATION ALWAYS?
Whether or not to admit a patient with pericarditis is a doctor's decision. The latter, after making sure of the health condition of the sick individual, and based on the diagnosis made, will decide what to do.
Conditions that require hospitalization:
- High fever, above 38 degrees
- High number of white blood cells in the blood due to a serious infection
- Pericarditis caused by thoracic trauma
- High levels of troponin in the blood (NB: troponin is a protein found mainly in the voluntary muscles and in the heart. When there is muscle damage to the heart, the concentration of troponin in the blood increases abnormally)
- Risk of a cardiac tamponade
- Pericarditis requiring surgery
PHARMACOLOGICAL TREATMENT
It is essential to know for what reasons a pericarditis has arisen, as this allows the doctor to determine which drugs are most appropriate. For example, a viral pericarditis requires drugs other than a bacterial pericarditis; or, if at the origin there is a heart attack, some pharmacological treatments must be excluded, because they could worsen the patient's health conditions.
In summary, therefore, the most used drugs are:
- NSAIDs (non-steroidal anti-inflammatory drugs), including aspirin, ibuprofen etc.
- Narcotic analgesics
- Colchicine
- Corticosteroids
- Antibiotics
NSAIDs
NSAID treatment is used to reduce inflammation and relieve chest pain. Therefore, in addition to an anti-inflammatory action, they are also administered as analgesics.
The most used drugs are ibuprofen and aspirin . The former is very effective in almost all circumstances of pericarditis, except in cases where there is a heart attack at the origin of the disorder. In these situations, aspirin is used and excellent results are obtained.
Side effects, due to prolonged use, consist of gastric ulcers (in the stomach). For this reason, very often, NSAIDs are associated with so-called proton pump inhibitors, which protect the stomach.
NSAIDs are also used in cases of recurrent pericarditis and exudative chronic pericarditis, with mixed results.
NARCOTIC ANALGESICS
Narcotic analgesics are opiates (morphine derivatives). They have excellent effects, however they should be administered for short periods and only if strictly necessary.
colchicine
Colchicine has an anti-inflammatory function, as it targets the cells of the immune system, which cause inflammation. Its administration may be associated with NSAIDs, if these have benefits, or isolated.
The action of colchicine, at the pericardial level, is effective: it reduces the symptoms and the risk of a relapse. However, in some cases, side effects may occur, such as abdominal pain, vomiting and diarrhea. With the habit of intake, these side effects can be greatly reduced.
Colchicine effectively prevents the onset of recurrent pericarditis.
Side effects of corticosteroids:
- Recurrent pericarditis
- Increased body weight
- Mood swings
- Excessive sweating
CORTICOSTEROIDS
Corticosteroids are used only when the NSAID and colchicine-based treatments do not provide any satisfactory results. This is an extreme measure, as these drugs, especially in prolonged treatments, can have serious side effects.
Corticosteroids act at the level of the immune system, reducing the number of inflammatory cells and, consequently, also the pain.
To learn more: Drugs for the treatment of Pericarditis ยป
OTHER THERAPEUTIC MEASURES
If it is found that the pericarditis has bacterial origin, the therapeutic treatment involves the use, in addition to the aforementioned analgesic drugs, of antibiotics .
If at the origin of the disorder there is a heart problem, such as a myocarditis or even more so a heart attack, rest should be added to the appropriate drug therapy.
SURGERY: HOW AND WHEN TO ACT
The surgical operation is reserved for the most serious cases of pericarditis, characterized by complications.
There are two methods of intervention and the choice of one or the other depends on the type of complications that have arisen in the patient.
- Pericardiectomy . It is the removal of the pericardium. It is used when the patient has developed chronic constrictive pericarditis. In these subjects, the pericardium has become stiff following the continuous inflammatory state and no longer allows the heart to pump blood in a normal way. This is a very delicate operation, which in one case out of 20 can determine the death of the patient. Therefore, action is taken only if strictly necessary. Hospitalization is planned.
- Pericardiocentesis . It is the aspiration of pericardial fluid, when this is in excess due to the inflammatory state. The presence of too much liquid between the two layers of pericardium prevents the heart from functioning properly and pushing the blood into circulation (as happens in cases of chronic exudative pericarditis and / or cardiac tamponade). To aspirate the fluid, a sterile, needle-like catheter is used, which is led to the pericardium. Drainage is repeated for several consecutive days, therefore it requires hospitalization. Everything is done under local anesthesia.
Prognosis
The prognosis related to pericarditis depends on the clinical case under examination. As we have seen, in fact, the inflammation of the pericardium can have different causes and, according to these, more or less serious pathological circumstances will be established.
For example, viral pericarditis usually resolves positively in a few weeks, especially if the right pharmacological treatments are applied.
In contrast, a pericarditis due to some more serious heart disease, such as a myocarditis or heart attack, does not have a positive prognosis as the previous case. It requires more attention and there is a risk that the disorder will recur later in time.
A condition of recurrent or even chronic pericarditis affects the quality of life of an individual.
Surgery, although reserved for the most severe cases, is delicate and presents a small percentage of risk to the patient.
